Transradial Arterial Access: Economic Considerations

ABSTRACT: The economic benefits of transradial compared to transfemoral access for percutaneous coronary procedures are derived from advantages primarily related to a lower incidence of access site complications and earlier ambulation. While multiple aspects of transradial access are associated with economic benefit, a reduced incidence of complications with transradial access appears to provide the greatest magnitude of cost reduction. J INVASIVE CARDIOL 2009;21(Suppl a):18A–20A Key Words: Transradial, vascular complication, PCI
Compared with femoral arterial access, transradial access for percutaneous cardiac procedures is associated with 1) fewer access site complications and 2) earlier ambulation.^1–12 These two benefits are primarily important in achieving improved patient safety and comfort. However, they also confer an important secondary economic advantage. The purpose of this article is to examine this advantage. Reducing Vascular Complications It is well established that vascular access complications following catheter-based procedures result in increased procedure and hospital-related costs.^13–25 Incremental costs are contributed to by 1) requirements for diagnostic vascular imaging, 2) additional laboratory costs, 3) blood transfusions, 4) vascular repair procedures, and 5) increased length of hospital stay. An example of the representative charges related to these additional tests and interventions for a hospital in the northeastern United States is elucidating (Table 1). It is important to consider that these charges do not accurately reflect cost. Additive indirect costs are related to factors such as fixed overhead, increased nursing intensity, and additional utilization of support staff, which must also be considered. Furthermore, little additional reimbursement can be expected to offset these costs. The magnitude of the negative economic impact of a vascular access complication has been quantified. Kugelmass et al reviewed data from Medicare patients undergoing PCI (n = 335,477) and demonstrated adjusted incremental costs of $4278 for those experiencing a vascular complication.¹6 Analysis from the Mayo Clinic PCI Registry demonstrated an incremental cost of $5883 for bleeding events.¹⁷ Regression modeling from the ACUITY trial revealed significant additional costs for minor ($2282) and major ($8658) bleeding events.¹⁸ A recent single-center multiple-regression analysis of GUSTO definition bleeding after non-urgent PCI showed a progressive increase in-hospital costs with minor ($4,310), moderate ($6,980), and major ($14,006) events.²¹ It is therefore rational to expect a significant decrease in costs with any technique or device that reduces the incidence of vascular complications. The avoidance of vascular complications associated with transradial access provides the greatest cost benefit related to this approach. Several studies have demonstrated that, compared with femoral arterial access, the transradial approach has been associated with a significant reduction in vascular access site bleeding complications.^1–12 It is notable that this benefit was seen in even the earliest randomized experiences of Kiemeneij (0% versus 2.0%, p = 0.03) and Mann (0% versus 4.0 %, p1,2 In a large meta-analysis of 12 studies (n = 3244) the incidence of vascular complications after transradial procedures was significantly lower than that seen in transfemoral cases (0.3% versus 2.8%, p 3 More recent studies confirm these initial findings and demonstrate benefit in regard to reduced access site bleeding complications. This reduction in complications extends to high risk subgroups such as women, obese patients, the elderly, acute coronary syndrome, primary PCI and rescue PCI patients.^5–11 Importantly, recent data from the MORTAL study and PRESTO-ACS vascular sub-study suggest that this reduction in access site complications also results in a mortality benefit for those patients undergoing PCI by the radial rather than the femoral route.^9,12Early Patient Mobility Early ambulation provides potential cost reduction and economic benefit through various avenues, including expedited room turnover/increased throughput (both through the catheterization laboratory and same-day/recovery unit); decreased intensity of care required by nursing and support staff; shorter length of stay; enhanced ability to perform same-day PCI; and a more rapid return to productivity for working patients. The economic benefits of transradial PCI were first described by Kiemeneij in 1995. Transradial stenting demonstrated a 45% cost reduction compared to transfemoral stenting driven mainly by a significantly shorter length of hospital stay.²⁵ Mann et al, in a randomized study of 142 patients, demonstrated a 15% decrease in hospital charges with transradial stenting. In this study, total charges were significantly reduced with transradial access compared to the femoral approach ($20,476 ± 811 versus $23,389 ± 1,180; p p 26 A randomized single-center study by Cooper et al demonstrated a significant reduction in hospital costs for transradial versus transfemoral diagnostic catheterization ($2010 versus $2299; p 27 Amoroso et al quantified the workload for both catheterization laboratory and recovery area nurses following 260 consecutive transradial (n = 208) and transfemoral (n = 52) procedures. The workload was significantly reduced for transradial procedures (TR = 86 minutes versus TF = 174 minutes; p 29 Wiper et al reported zero incidence of vascular complications in a series of 442 patients treated with outpatient transradial coronary stenting.³⁰ A series of 1000 patients with acute coronary syndromes treated with transradial coronary stenting with adjunctive abxicimab and randomized to outpatient versus overnight care demonstrated no significance in major bleeding between groups (0.8% versus 0.2%; p = NS). These studies point out the advantage of transradial PCI as an attractive access option for outpatient PCI. Cohen et al compared economic data from elective single vessel transfemoral coronary stenting with a traditional overnight hospital stay to data from 100 consecutive patients treated by transradial single vessel stenting and same-day discharge. Costs were decreased by the latter strategy by over $1000.³² Expedited ambulation has also been demonstrated with vascular closure devices.^33–36 Mann and colleagues studied a consecutive series of matched patients (n = 209) treated with transradial stenting versus transfemoral stenting followed by suture mediated arterial closure. Although primary success rates, length of hospital stay and percentage of patients discharged the same day were similar between groups, costs in the transradial group were significantly lower due to fewer access site complications and lower supply costs.²⁶ A similar study comparing costs for transradial access versus transfemoral access with a vascular closure device revealed significantly shorter post-procedure recovery interval (126 ± 36 minutes versus 150 ± 48 minutes; p p 37 Early ambulation and a secure access site may also allow for an earlier return to productivity. Discharge instructions at our Institution advise patients to abstain from vigorous activities and lifting objects heavier than 5 pounds for 1 week after transfemoral access, but only 4 days after transradial access. This provides obvious benefit for employed patients returning to jobs with these requirements. It is also rational to expect that those patients experiencing access site complications, significantly more frequent with transfemoral access, would be delayed in returning to work by an extended recovery. One challenge related to transradial access stems from a relatively long learning curve, during which increased fluoroscopy times, procedure times, and decreased procedure success compared to transfemoral access can be anticipated.38,39 The economic implications are increased costs for specialized arterial access equipment (such as micropuncture kits), increased catheter usage, increased overhead related to nursing time and decreased room turnover. 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